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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200997
Report Date: 12/20/2022
Date Signed: 01/25/2023 11:33:59 AM

Document Has Been Signed on 01/25/2023 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CAUNTAY BOARD AND CARE HOMEFACILITY NUMBER:
275200997
ADMINISTRATOR:CAUNTAY, GAUDIOSAFACILITY TYPE:
735
ADDRESS:944 ESTRADA WAYTELEPHONE:
(831) 422-1845
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY: 6CENSUS: 5DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee, Gaudiosa, CauntayTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Gaudiosa, Cauntay Continual Administrator's Certification expires 03/05/2023. There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 114 degrees. First Aid kit is on site and complete.

LPA Hurt observed toxins unlocked and accessible to residents inside the garage, and in a shed in the backyard area.

There following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Gaudiosa Cauntay and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2023 11:33 AM - It Cannot Be Edited


Created By: Sarah Hurt On 12/20/2022 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAUNTAY BOARD AND CARE HOME
FACILITY NUMBER: 275200997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)

80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation chemicals, and cleaning solutions were unlocked and accessible to residents inside the garage, and outdoor shed areas which poses an immediate health, safety, or personal rights risk to residents in care.
POC Due Date: 12/21/2022
Plan of Correction
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Licensee will send proof of staff training on hazardous chemicals to LPA by 12/21/2022 POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022


LIC809 (FAS) - (06/04)
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